PITTSFIELD — If drug users could inject themselves under medical supervision and without the threat of getting arrested, it could save lives. But would the community support such a bold step, rife with moral and legal questions on both sides of the issue?

The county's top law enforcement official, District Attorney Andrea Harrington, says bringing supervised drug consumption services to Berkshire County is a conversation worth having because it's "an idea that maybe would work."

Earlier this year, Harrington and elected prosecutors from elsewhere in the United States visited Portugal to witness that country's progressive drug policies.

Portugal's medically supervised injection services — there, medical staff travel around in vans, providing sterile syringes and immediate care in the event of an overdose — have helped cut back the country's drug mortality rate to one of the lowest on record.

More than 100 supervised consumption sites exist in 11 other countries, with most in Germany, Spain, the Netherlands, Norway, Luxembourg and Denmark, where medically supervised injections are seen as a way to prevent fatal overdoses and the spread of disease from needle sharing. Canada has two sites and Australia has one.

The strategy hasn't been implemented in the United States, where roughly 70,000 people die each year from opioid-related overdoses. But in pockets of the country, including Massachusetts, it's under study and consideration. Seattle and San Francisco are moving toward operating supervised injection sites, while Philadelphia is the closest to opening one but is battling the federal government over its legality.

In March, a Massachusetts panel commissioned by the Legislature recommended a pilot program in supervised drug consumption. Lawmakers have yet to act on the controversial measure, and some have assailed inaction as a potential death sentence for some drug users.

"I know that the idea of safe consumption sites is uncomfortable to many, but if they are proven to save lives, then we have an obligation to at least give them a try," state Sen. Cindy Friedman, who served on the Harm Reduction Commission, said earlier this year in a report by State House News Service. "Lives are at stake and we cannot wait any longer."

Harrington acknowledged hurdles to clear in terms of building community support for the service in Berkshire County.

"There would need to be a much bigger conversation," she said. "What I'm saying is, it's an idea that maybe would work."

After a statewide doubling of overdoses from 2000 to 2010, Massachusetts Gov. Charlie Baker declared the opioid epidemic a public health emergency in 2014. That declaration directed state money and resources to fight drug addiction, but Baker doesn't support supervised injection sites, because the federal government considers them illegal.

Benefits seen

At supervised injection sites, medical staff don't provide illegal drugs or assist with injections, but provide clean equipment, consultation and intervene in the event of an overdose.

Australia's one medically supervised injection site, in an inner-city neighborhood in Sydney, had "150 visits a day and has managed nearly 6,000 overdoses with no overdose fatality" between the time it opened in 2001 and 2017, according to that country's Alcohol and Drug Foundation.

The foundation, formed 55 years ago, initially to help combat veterans with alcohol and drug dependency, backs opening more sites in Australia. Sydney's injection site also has cut ambulance calls, reduced street-level drug use and public nuisances and halved the number of discarded needles tossed in public places, according to the foundation.

In Berkshire County, County Ambulance looks to launch an overdose follow-up program in the coming months, and Harrington said it's the kind of program that could one day expand to include supervised injection.

Brian Andrews, president of the 10-vehicle countywide service, said he plans to talk with Harrington about the possibility of adding those mobile services.

"I can see where there could be a lot of benefits to it," Andrews said.

Andrews said supervised injection would save Berkshire lives and reduce resources spent on overdose calls, which, he said, make up roughly 2 percent of the service's 15,000 annual calls. Responding to people before they overdose would help control the chaos, he said.

"It's less of a depletion of our first responder resources," Andrews said. "It keeps emergency responders available to do their job."

In the United States, a nonprofit in Philadelphia is closest to developing a program, yet its efforts attracted a lawsuit from the federal government, which argues that injection sites are illegal. In that case, Harrington joined 32 other elected prosecutors from around the country, including Philadelphia District Attorney Larry Krasner, in filing a brief last month in support of supervised consumption.

Public health officials in Philadelphia estimate that if one site opened in the city, it would save 76 lives from overdose, as well as prevent HIV diagnoses and dozens of new hepatitis C cases, a year, according to a court brief they filed. In addition, they predict that a site could save the city nearly $124,000 a year in emergency ambulance calls related to overdoses.

The Philadelphia nonprofit also faces opposition from civic associations and police groups in the region.

Harrington said she signed the brief because she believes the sites are legal under federal law. "And also that safe consumption sites enhance public safety."

In Berkshire County, Department of Public Health statistics show that 40 people died last year from an opioid-related overdose, and 210 overdose deaths occurred in the Berkshires from 2010 to 2018.

In Massachusetts, 2,033 people died in 2018 from opioid-related overdoses. According to the Harm Reduction Commission, fentanyl is present in 89 percent of opioid-related overdose deaths in Massachusetts. Fentanyl, a synthetic opioid, affects the body faster than heroin, and "overdoses can occur within minutes of ingestion," according to the Harm Reduction Commission.

In Berkshire County, there was a steady increase in opioid-related overdose deaths from 2010 to 2016, ranging from four to 35 deaths each year. In 2017, the number declined slightly, to 28 fatal opioid-related overdoses, before jumping to 40 deaths in 2018.

Overdose deaths involving synthetic opioids other than methadone, which includes fentanyl, increased almost 47 percent nationwide from 2016 to 2017, according to the Centers for Disease Control and Prevention.

Much of the synthetic opioid overdose increase might be due to illegally or illicitly made fentanyl, which is 50 times more potent than heroin, the CDC said.

Legal reluctance

Harrington said she understands why Baker, who has made opioid addiction a focus for his administration, and other leaders are hesitant to sanction supervised injection while the court battle plays out.

"It is not realistic to set up safe consumption sites in this legal landscape," Harrington said.

Despite the Harm Reduction Commission's recommendation, Baker dismissed supervised injection sites in Massachusetts over legality concerns.

"The U.S. attorney (Andrew Lelling) has made it absolutely crystal clear that he will prosecute anyone who tries to open up a safe injection site in Massachusetts," Baker said in March, as quoted by The Associated Press. "Chasing something that's not legal under federal law just doesn't make a lot of sense."

Instead, Baker said he supports legal methods to help drug users, such as needle exchange programs and expanding access to overdose-reversal drugs.

Harrington said the Philadelphia case could, however, pave a path for Massachusetts.

Here in the commonwealth, the Harm Reduction Commission points to an overdose crisis that supervised consumption sites could address. Massachusetts ranks among the top 10 states with the highest rates of opioid-related overdose deaths, according to the group's report.

The commission, formed last year by the Legislature, and made up of public officials and medical professionals, studied supervised consumption sites in Canada to inform its findings. Beyond the initial oversight, the report says such sites might also offer sterile injecting equipment to take home, counseling services, primary medical care, testing for HIV and hepatitis C and referral to other services.

Harrington said supervised injection services fall in line with the harm-reduction approach her office is taking on drug crimes.

"We would like to see them here in Berkshire County, but we also recognize that there needs to be community support for that."

If, down the road, the community is on board and medical partners come through, she said she would work with legislators to bring pilot funds into Berkshire County for the initiative.

Local leaders cautious

Other Berkshire County law enforcement officials and politicians were more hesitant to talk about supervised injection. Most interviewed for this story said they didn't know enough about how it works to have a strong opinion.

Sheriff Thomas Bowler said an exhaustive conversation still needs to happen more broadly because of outstanding legal and moral questions.

"Some serious and intense thought needs to go into this at the state and federal level," he said.

State Rep. William "Smitty" Pignatelli, D-Lenox, said it strikes him as unethical to provide that kind of haven for heroin.

"My gut tells me there's something particularly wrong with that," Pignatelli said. "I just want to make sure we're spending as much if not more time trying to get these people into treatment as we are helping to get them high."

In the Berkshires, Pignatelli said he'd sooner see more resources go toward recovery and prevention.

"The jury's still out with me," he said.

We're all still learning how best to deal with the opioid epidemic, said state Rep. Tricia Farley-Bouvier, D-Pittsfield.

"We just need to keep our minds open," she said. "What is really going to save lives?"

Farley-Bouvier said supervised injection keeps people safe while they're making bad decisions, protecting them from overdosing on fentanyl that is making its way into more heroin doses.

"During that time there's counseling and relationship building to move people towards less harmful behavior," she said.

But the legal landscape is tricky, Farley-Bouvier said, and because supervised injection is so unfamiliar to the commonwealth, it should perhaps start with a pilot program in Boston, "so that we can see what's working."

"Fighting an epidemic requires focusing on saving lives and doing what it takes to turn the corner while keeping people safe," said state Sen. Adam Hinds, D-Pittsfield. "If safe injection sites can achieve that, we should include that in our effort to take this head-on."

Given the hundreds who die from overdoses each year in Massachusetts, state Rep. John Barrett III, D-North Adams, said supervised injection is not something to brush off. But the prospect is deeply controversial, he said, and outstanding legal questions make the issue intractable.

"There's many hurdles that have to be overcome, and they have to begin at the local level," he said.

Both Berkshire mayors said they don't know much about supervised injection, but community buy-in would be key.

Pittsfield Mayor Linda Tyer said supervised injection is not something she has thought a lot about or researched.

"I do feel like it's premature for me to take a position on this," she said.

"One of the things that would matter to me as the mayor is that we give careful thought to the impacts that a safe injection site would have on community life."

"There's certainly no harm in talking," North Adams Mayor Thomas Bernard said. "I would need to learn and hear and see a lot more about what it might look like, how other places have experienced it."

Bernard said the opioid problem is too vast not to consider something that could help.

"This is a war being fought on many fronts in every corner of Berkshire County, in every corner of Massachusetts and every corner in the country," he said. "We can't afford to not explore strategies that mitigate risk, mitigate harm."

Pittsfield Police Chief Michael Wynn said he'd like to at least take a look at any initiative that could potentially save lives, but without having a specific program to size up, it's hard for him to weigh in.

"There's a lot of unanswered questions," he said.

He'd have to consider how the program would fit in with police officers, he said, and the job they have to do.

"We still have to have a plan to deal with the illegal activity," he said.

On the ground

Too often, Andrews, of County Ambulance, said his staff show up to calls and find people who have overdosed and died. There was no one there to revive them.

"They didn't intend to overdose," he said. "Certainly, the drug that they're getting is not quality controlled. People overdose never intending to."

Andrews said he prefers to call supervised injection facilities "overdose prevention centers." That way, "we're keeping them alive until they're ready to make that decision for recovery."

He said supervised consumption services also help cut back on diseases related to intravenous drug use.

"Right now, hepatitis is really the big issue," he said.

Dr. Ardis Fisch of SaVida Health, a suboxone clinic in Pittsfield, said safe injection sites would reduce the amount of paraphernalia in the home. Fisch said she once had a patient whose 3-year-old niece contracted hepatitis C from a dirty needle discarded at the patient's house.

"None of that would be in a house," she said. "Every time you go, you would get clean stuff."

And if parents are using heroin at the site, it would mean they aren't doing it in front of their children.

"Here's this huge thing you can do and save lives for people who are not yet ready for treatment," she said. "It's harm reduction for the whole family."

One of the challenges to implementing these services will be getting the general public over the "ick factor" of knowing that people are using heroin in their neighborhood, Fisch said.

What people aren't considering is that people are already using and, in some cases, discarding their paraphernalia on the same streets.

At "every bus station, people are doing drugs and overdosing," she said.

Those who support the sites aren't sanctioning drug use, Fisch said, but rather acknowledging that it's happening and trying to keep people alive.

"If they're going to be using, I'd prefer them to use clean needles," Fisch said of her patients.

The same can be said for the Healthy Steps program in Pittsfield, which provides clean syringes and disease screening for people who are addicted. The program's testing data shows a recent uptick in hepatitis C cases — 23 people tested positive for the disease from January through June, or about 8 percent of the tested population. That's trending up from about 5 percent last year, and 4 percent in 2017.

Between 2015 and 2017, there were 468 hepatitis C cases in Berkshire County, according to Ann Scales, a DPH spokeswoman.

And if preventing death and disease isn't enough motivation, Fisch said people should support the idea of supervised injection services because they will likely reduce the amount of emergency resources spent on overdoses.

"Even if your feeling is `They're junkies and let them die' — there are people who say that out loud — would you like the police to be available when someone breaks into your house? Would you like an ambulance available when you have a heart attack?"

Amanda Drane can be contacted at adrane@berkshireeagle.com, @amandadrane on Twitter, and 413-496-6296.

Haven Orecchio-Egresitz can be contacted at horecchio@berkshireeagle.com, @haveneagle on Twitter, and 413-770-6977.